BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA ""` �� °,� ` STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM B `� /t COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL SED ON SI ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY TANK CLOSURE 8 TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: 50 A I. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A OWNERS TANK 1.D.M B. MANUFACTURED BY: C. DATE INSTALLED(MODAY/YEAR) D. TANK CAPACITY IN GALLONS: ILTANK CONTENTS IFA-11S MARKED.COMPLETE ITEM C. q ,><Il MOTOR VEHICLE FUEL ❑ 4 OIL B. C. 1e REGULAR UNLEADED 3 DIESEL ❑ 8 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY i PRODUCT ❑ 10 PREMIUM UNLEADED 4 GASAHOL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 1C MIDGRADE UNLEADED ❑ 5 JET FUEL ❑ B M85 2 LEADED ❑ 99 OTHER(DESCRIBE IN REM D.BELOW) D. IF(A1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A S.Y III. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A B,AND C,AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF ❑ 1 DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 5 INTERNAL BLADDER SYSTEM ❑ 95 UNKNOWN SYSTEM 2 SINGLE WALL ❑ 4 SINGLE WALL IN A VAULT ❑ 99 OTHER B. TANK >1 BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 8 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 10D% METHANOL COMPATIBLE W/FRP (pd"'W T-k) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER ❑ 2 ALKYD LINING 3 EPDXY LINING C.INTERIOR 1 RUBBER UNED 4 PHENOLIC LINING ❑ ❑ LINING OR ❑ 5 GLASS LINING UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER COATING IS LINING MATERIAL COMPATIB WITH 100% METHANOL? YES_ NOZS D.EXTERIOR ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCED PLASTIC CORROSION '1 PROTECTION ❑ 5 CATHODIC PROTECTION�91 NONE ❑ 9S UNKNOWN ❑ 99 OTHER E SPILL AND OVERFILL,BLD. SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) 1• DROP TUBE YES_ NO_ STRIKERPLATE YES_ NO DISPENSER CONTAINMENT YES NO IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A& SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 4 FLEXIBLE PIPING A U 99 OTHER B. CONSTRUCTION A SINGLE WALL A U 2' DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND &QI"D I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U B CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE WIFRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION 1 wc9=ME IEAIt 2 UNE TKMNE35 3 cart .WRASTIMI 4 DEcm n U9E s AvrouAnc PwP ❑ OE1ECfOR ❑ TEST9IG ❑ MONTOANG [TAI(DETECTOR ❑ SHownc ❑ 99 OTHER V.TANK LEAK DETECTION ❑ 1 VISUAL CHECK ❑ 2 RECONCILIATIONNUAL INVENTORY ❑ 3 MONIITORING ❑ 4 GAUGING AUTOMATIC TANK ❑5 MONITORINGOUND TER ❑ 6 TESTINGTANK ❑ 7 MONITORING INTERSTITIAL ❑ B SIR ❑ 9 TANK GAU ANGAL ❑10 MOTESNTHLY TANK ❑ 95 UNKNOWN 99 OTHER NG VI.TANK CLOSURE INFORMATION(PERMANENT CLOSURE IN-PUCE) �/ 1.ESTIMATED DATE LAST U E M A R) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES ❑ NO 17�L, SUBSTANCE REMAINING GALLONS INERT MATERIAL 7 J < THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME DATE (PRINTED A SIGNATURE) LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY N JURISDICTION# FACILITY 73/ TANK N OO STATE I.D.# 6=6 (D U �, PERMIT NUMBER PERMIT APPROVED BYIDATE PERMIT EXPIRATION UA THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FORM C MUST BE COMPLETED FOR INsT ONS IS FORM SHOULD BE ACCOMPANIED BY A PLOT PLO" FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNnERGROUND STORAGE TANK REGULA77ONS FORME (&95) `� -me 6 .-& ��